Insufficient documentation is documentation that was incomplete, inaccurate or was missing from the medical records. Below is a list of the most common reasons CERT determined there was insufficient documentation that caused improper payments for HBO therapy treatments.
Treatment Plan: HBO treatment plan should include atmospheric pressures, rest/air breaks, frequency and number of dives, blood glucose monitoring, wound assessments and evaluation of progress.
Treatment Records: should include start and stop times of the HBO treatment, documentation to support when blood glucose measurements are taken and the results (if applicable).
Wound Records: wound flow sheets supporting measurable signs of healing, wound measurements, subjective findings regarding the wound.